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Group Health Plans | More than 50 Employees

BlueEdge Comprehensive Major Medical Program (40% Coinsurance)

Employer groups may select from a choice of deductible options.

Basic plan summary Member pays
Deductible (per group anniversary benefit period) $1,500/$3,000; $2,500/$5,000; $3,500/$7,000 individual/two-or-more persons
Coinsurance (member portion for most services) 40% of allowed amounts after deductible has been met
Coinsurance maximum $2,000/$4,000 individual/two or more persons
Maximum out-of-pocket (includes copays, deductible and coinsurance where applicable) $6,350/$12,700 individual/two-or-more persons.
After the maximum out-of-pocket amount has been reached, eligible benefits will be paid at 100% of the allowed amount for the remainder of the benefit period.
Doctor's office visits
Home and office visits $30 office visit copay on first five visits, then subject to deductible/coinsurance*
Telehealth visits $30 office visit copay on first five visits, then subject to deductible/coinsurance*
Home and office visits – Specialist $60 office visit copay on first five visits, then subject to deductible/coinsurance*

*Combined limit of primary, specialist & telehealth office visits.
Preventive care as defined by the Affordable Care Act These services are paid at 100% of the allowable charge.
Some of the services include:
  • Routine screenings
  • Preventive immunizations
  • Well-woman visits/screenings
  • Contraceptive methods
Drug coverage
Prescription drugs and mail order The quantity per prescription is a 30-day pharmacy supply
or 90-day mail order supply.

BlueRx Card $15/$30/$45; $90/20% up to $250 with mail order is 2½ x copay with ResultsRx formulary. Must use designated specialty pharmacy for all specialty prescriptions.
BlueRx Card $15/$50/$75; $150/20% up to $250 with mail order is 2½ x copay with ResultsRx formulary
BlueCare Card $15 generic, $100/$200 deductible then preferred brand-40% coinsurance (member pays) with a minimum of $30 or whichever is greater AND non preferred brand-60% coinsurance with a minimum of $50 or whichever is greater
Mail order is 21/2 x copay ($37.50) for generic, preferred brand-40% coinsurance with a minimum of $75 or whichever is greater and non-preferred brand-60% coinsurance with a minimum of $125 or whichever is greater with ResultsRx formulary.

Must use designated specialty pharmacy for all specialty prescriptions.
Medical services
Emergency medical transportation Subject to deductible/coinsurance
Inpatient surgery physician/surgical
Inpatient facility fee
Outpatient surgery physician/surgical
Outpatient lab and radiology (includes advanced imaging)
Emergency room $250 copay then subject to deductible/coinsurance
Recovery/special needs
Outpatient rehabilitation Subject to deductible/coinsurance
Hospice
Home social work visits
Short-term therapies – Physical, speech and occupational, respiratory and cardiac Subject to office visit copay based on specialty.
(Visits count towards the five office visit limit per benefit period. Office visits are subject to deductible/coinsurance starting with the sixth visit) and subject to outpatient short term therapy visitation limits (regardless of place of service):
Outpatient speech therapy: 30 visits
Outpatient rehab: 40 visits
Spinal manipulations: 20 visits
Mental health
Mental/behavioral health – inpatient services
Requires pre-admission certification from New Directions Behavioral Health at (800) 952-5906
Subject to deductible/coinsurance
Mental/behavioral health – outpatient services $30 office visit copay
Other
Lifetime maximum Unlimited
Eligible dependents Covered to age 26

Exclusions: Following is a list of common non-covered services. For a complete list of limitations and exclusions, refer to your certificate.

Duplicate benefits provided under federal, state or local laws, regulations or programs except Medicaid; services involving cosmetic or reconstructive surgery (except as stated in the contract); charges for personal items; convalescent or custodial care or rest cure; all keratotomy procedures; blood or payments to donors of blood; any service or supply related to the medical management of obesity, except services covered as preventive health benefits; services or supplies related to sex transformations; services related to the reversal of sterilization procedures; any medically-aided insemination procedure; charges for services by immediate relatives or by members of the household; acupuncture and admission for acupuncture; medically unnecessary services and admissions; services covered and payable under any medical expense payment provision of any automobile insurance policy; mental illness or substance use disorder services provided by a non-eligible provider; services, supplies or treatments not specifically listed as covered in the member’s contract.

Drug coverage limitation: Generic drugs are mandatory if available unless physician prescribes a brand drug.

Optional benefits:

Additional program information

  • Inpatient admissions – Pre-admission certification is required for all planned inpatient admissions.
  • Benefit period – The 12-month period based on the group anniversary month.
  • Waiting period – Businesses select a waiting period option.

Triple Option Plan
The Triple Option Plan is available to large groups with this product. The plan offers employees one of three out-of-pocket choices annually within the Comprehensive Major Medical benefit program. The employer must contribute at least 25 percent of the employee-only premium amount for the highest out-of-pocket option. This stabilizes the group's base and gives the employees the option to "buy up" to a better level of coverage, based on their personal insurance needs.

More information
Contact us to learn more about the features of BlueEdge Comprehensive Major Medical.

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